2010 Black Belt Camp Registration

July 29th - July 30, 2010

Name * First Last
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone * - (###) - ### ####
Age (as of camp) *
Dojo *
Empty Hand Rank and Date of Promotion *
Kobudo Rank and Date of Promotion
Teaching Rank and Date of Promotion
Name of Chaperone (if under age 19) First Last
Room Preference *

If we cannot accommodate your request for a quad or triple, we may have to upgrade your room to a double and charge you accordingly. Additional charges will be settled at camp. Payment information will be collected on next page.
Name(s) of people you wish to share room with:
Dietary Needs

If you have any special dietary requirements, including foods you cannot eat you must specify now or you will be served the planned selections. Liberty Mountain cannot make last minute dietary changes.
To complete your registration select "Continue" below. You will be given a chance to review your registration information and then taken to the payment page.